A comparison of two techniques to identify the sex of the eastern blue-tongue skink (Tiliqua scincoides scincoides)

INTRODUCTION

The eastern blue-tongued skink (Tiliqua scincoides scincoides), native to eastern Australia, is commonly kept as both a pet and for breeding. As a sexually monomorphic species, it is important to develop reliable techniques for sex identification, both for breeding and health purposes. Numerous techniques have been developed for the identification of sex in other reptile species but, other than possibly morphometric analysis, none have proven to be reliable in this species. Two techniques showing promise are contrast radiography of the hemepenes/hemeclitores, and morphometrical analysis. This study looks at both techniques and compares them for accuracy.

METHODS AND MATERIALS

Twenty captive eastern blue-tongued skinks (of known sex) were sedated, contrast radiography of their hemepenes /hemeclitores was performed, and physical measurements were taken for morphometric analysis. The radiographs were examined by a panel of three researchers (blinded to the known sex) to identify sex. The morphometric data were statistically analysed, following a previously published methodology, and the individual sex identified. Again, the researchers were blinded to the known sex.

RESULTS

The contrast radiography technique was 100% accurate in correctly identifying the sex of all the skinks. Morphometric analysis was, by contrast, only 70% accurate.

CONCLUSION AND CLINICAL RELEVANCE

Physical differences between wild and captive skinks, as well as different environmental and nutritional factors, may have contributed to the lower accuracy of morphometric analysis in identifying the sex of eastern blue-tongued skinks. While contrast radiography was more accurate, the need for specialised equipment may render this technique impractical for field researchers, but more suitable for owned animals. More research is needed to assess the impact of captivity on eastern blue-tongued skinks' physical morphometrics.

Movement System Theory and Anatomical Competence: Threshold Concepts for Physical Therapist Anatomy Education

This viewpoint proposes eight anatomy threshold concepts related to physical therapist education, considering both movement system theory and anatomical competence. Movement system theory provides classifications and terminology that succinctly identifies and describes physical therapy practice from a theoretical and philosophical framework. The cardiovascular, pulmonary, endocrine, integumentary, nervous, and musculoskeletal systems are all included within this schema as the movement system theory encompasses all body systems interacting to create movement across the lifespan. Implementing movement system theory requires an ability to use human anatomy in physical therapist education and practice. Understanding the human body is a mandatory prerequisite for effective diagnosis, assessment, treatment, and patient evaluation. Anatomical competence refers to the ability to apply anatomic knowledge within the appropriate professional and clinical contexts. Exploring the required anatomical concepts for competent entry-level physical therapist education and clinical practice is warranted. The recommended threshold concepts (fluency, dimensionality, adaptability, connectivity, complexity, stability or homeostasis, progression or development, and humanity) could serve as an integral and long-awaited tool for guiding anatomy educators in physical therapy education.

Call for Consistency: the Need to Establish Gross Anatomy Learning Objectives for the Entry-Level Physical Therapist

A need currently exists for the establishment of anatomy learning objectives for physical therapist education programs. Developing recommended anatomy objectives to serve as a curricular guide may foster more consistent student outcomes while preserving instructional autonomy. These objectives could serve as a vital resource when making decisions during curricular reform or prioritizing and emphasizing the curriculum's anatomic content. We advocate for collaboration amongst anatomy faculty and clinicians to create specific and measurable anatomy learning objectives for the entry-level physical therapist. It is essential that the objectives be peer-reviewed and that they reflect a global consensus.

Intense Arm Rehabilitation Therapy Improves the Modified Rankin Scale Score: Association Between Gains in Impairment and Function

OBJECTIVE

To evaluate the effect of intensive rehabilitation on the modified Rankin Scale (mRS), a measure of activities limitation commonly used in acute stroke studies, and to define the specific changes in body structure/function (motor impairment) most related to mRS gains.

METHODS

Patients were enrolled >90 days poststroke. Each was evaluated before and 30 days after a 6-week course of daily rehabilitation targeting the arm. Activity gains, measured using the mRS, were examined and compared to body structure/function gains, measured using the Fugl-Meyer (FM) motor scale. Additional analyses examined whether activity gains were more strongly related to specific body structure/function gains.

RESULTS

At baseline (160 ± 48 days poststroke), patients (n = 77) had median mRS score of 3 (interquartile range, 2-3), decreasing to 2 [2-3] 30 days posttherapy (p < 0.0001). Similarly, the proportion of patients with mRS score ≤2 increased from 46.8% at baseline to 66.2% at 30 days posttherapy (p = 0.015). These findings were accounted for by the mRS score decreasing in 24 (31.2%) patients. Patients with a treatment-related mRS score improvement, compared to those without, had similar overall motor gains (change in total FM score, p = 0.63). In exploratory analysis, improvement in several specific motor impairments, such as finger flexion and wrist circumduction, was significantly associated with higher likelihood of mRS decrease.

CONCLUSIONS

Intensive arm motor therapy is associated with improved mRS in a substantial fraction (31.2%) of patients. Exploratory analysis suggests specific motor impairments that might underlie this finding and may be optimal targets for rehabilitation therapies that aim to reduce activities limitations.

CLINICAL TRIAL

Clinicaltrials.gov identifier: NCT02360488.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for patients >90 days poststroke with persistent arm motor deficits, intensive arm motor therapy improved mRS in a substantial fraction (31.2%) of patients.

A Feasibility Study of Expanded Home-Based Telerehabilitation After Stroke

Introduction: High doses of activity-based rehabilitation therapy improve outcomes after stroke, but many patients do not receive this for various reasons such as poor access, transportation difficulties, and low compliance. Home-based telerehabilitation (TR) can address these issues. The current study evaluated the feasibility of an expanded TR program. Methods: Under the supervision of a licensed therapist, adults with stroke and limb weakness received home-based TR (1 h/day, 6 days/week) delivered using games and exercises. New features examined include extending therapy to 12 weeks duration, treating both arm and leg motor deficits, patient assessments performed with no therapist supervision, adding sensors to real objects, ingesting a daily experimental (placebo) pill, and generating automated actionable reports. Results: Enrollees (n = 13) were median age 61 (IQR 52-65.5), and 129 (52-486) days post-stroke. Patients initiated therapy on 79.9% of assigned days and completed therapy on 65.7% of days; median therapy dose was 50.4 (33.3-56.7) h. Non-compliance doubled during weeks 7-12. Modified Rankin scores improved in 6/13 patients, 3 of whom were >3 months post-stroke. Fugl-Meyer motor scores increased by 6 (2.5-12.5) points in the arm and 1 (-0.5 to 5) point in the leg. Assessments spanning numerous dimensions of stroke outcomes were successfully implemented; some, including a weekly measure that documented a decline in fatigue (p = 0.004), were successfully scored without therapist supervision. Using data from an attached sensor, real objects could be used to drive game play. The experimental pill was taken on 90.9% of therapy days. Automatic actionable reports reliably notified study personnel when critical values were reached. Conclusions: Several new features performed well, and useful insights were obtained for those that did not. A home-based telehealth system supports a holistic approach to rehabilitation care, including intensive rehabilitation therapy, secondary stroke prevention, screening for complications of stroke, and daily ingestion of a pill. This feasibility study informs future efforts to expand stroke TR. Clinical Trial Registration: Clinicaltrials.gov, # NCT03460587.

Social Network Structure Is Related to Functional Improvement From Home-Based Telerehabilitation After Stroke

Objective: Telerehabilitation (TR) is now, in the context of COVID-19, more clinically relevant than ever as a major source of outpatient care. The social network of a patient is a critical yet understudied factor in the success of TR that may influence both engagement in therapy programs and post-stroke outcomes. We designed a 12-week home-based TR program for stroke patients and evaluated which social factors might be related to motor gains and reduced depressive symptoms. Methods: Stroke patients (n = 13) with arm motor deficits underwent supervised home-based TR for 12 weeks with routine assessments of motor function and mood. At the 6-week midpoint, we mapped each patient's personal social network and evaluated relationships between social network metrics and functional improvements from TR. Finally, we compared social networks of TR patients with a historical cohort of 176 stroke patients who did not receive any TR to identify social network differences. Results: Both network size and network density were related to walk time improvement (p = 0.025; p = 0.003). Social network density was related to arm motor gains (p = 0.003). Social network size was related to reduced depressive symptoms (p = 0.015). TR patient networks were larger (p = 0.012) and less dense (p = 0.046) than historical stroke control networks. Conclusions: Social network structure is positively related to improvement in motor status and mood from TR. TR patients had larger and more open social networks than stroke patients who did not receive TR. Understanding how social networks intersect with TR outcomes is crucial to maximize effects of virtual rehabilitation.

An evaluation of a veterinary-specific mental health service

BACKGROUND

Veterinary professionals are at increased risk of suicide and mental health difficulties compared to the general population. Vetlife Health Support (VHS) is a mental health case management service for veterinarians with mental health difficulties.

AIMS

To evaluate the VHS case management service from the service user's perspective.

METHODS

Service users (n = 98) completed questionnaires assessing their experience with VHS and current mental health status using the Kessler-6 Scale. A sub-sample was interviewed and the data qualitatively analysed (n = 14).

RESULTS

The results show that 97% (n = 95) reported a positive experience with VHS and 98% (n = 96) reported VHS staff respected and listened to them. Participants reported significant improvements in relationships with others after VHS (P < 0.001) and were significantly more likely to be in receipt of formal mental health care after VHS than before (P < 0.01). The main emergent themes from the qualitative interviews were (i) positive communication between clinician and service users, (ii) veterinary-specific mental health services were regarded as important to understanding service users' circumstances, (iii) knowing someone is supporting them positively impacted wellbeing and (iv) confusion with discharge status.

CONCLUSIONS

Most participants reported positive experiences with VHS. Quantitatively, data showed that participants reported significant improvements in relationships and access to formal mental health care after contact with VHS. Interviews with service users revealed that they felt speaking to a mental health professional with veterinary-specific knowledge was beneficial for their wellbeing. Further evaluation assessing whether VHS leads to a measurable impact on psychological wellbeing is recommended.

Community Priority setting for Fetal Alcohol Spectrum Disorder Research in Australia

Introduction

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by prenatal alcohol exposure (PAE). FASD research is a rapidly growing field that crosses multiple disciplines. To ensure research is relevant and meaningful for people living with FASD, their families, and the broader public there is a need to engage community members in setting priorities for research.

Objectives

Our primary objective was to formally identify the views of people living with FASD, their parents/caregivers, service providers, and the general community on the research priorities for FASD and alcohol use in pregnancy in Australia. Our secondary objective was to provide an overview of current research in the highest priority areas identified.

Methods

The approach for this study involved two community surveys and a consensus workshop, followed by a rapid literature review. Survey responses (n = 146) were collected and grouped using qualitative thematic analysis. The themes identified were then ranked in a second survey (n = 45). The 22 highest ranked themes were considered in a workshop with 21 community members, and consensus on the top ten priority areas was sought. The priority areas were grouped into conceptually similar topics and rapid literature reviews were undertaken on each.

Results

A diverse range of priorities was identified within key areas of prevention, diagnosis, and therapy. On request from participants, separate priority lists were developed by Aboriginal and non-Aboriginal participants.

Conclusion

There is need for a national network of researchers to take forward the research commenced by the Centre of Research Excellence, FASD Research Australia, in addressing community priorities.

Key Words

Community, priorities, FASD, rapid review, Australia.

Facing the Ethical Challenges: Consumer Involvement in COVID-19 Pandemic Research

Consumer involvement in clinical research is an essential component of a comprehensive response during emergent health challenges. During the COVID-19 pandemic, the moderation of research policies and regulation to facilitate research may raise ethical issues. Meaningful, diverse consumer involvement can help to identify practical approaches to prioritize, design, and conduct rapidly developed clinical research amid current events. Consumer involvement might also elucidate the acceptability of flexible ethics review approaches that aim to protect participants whilst being sensitive to the challenging context in which research is taking place. This article describes the main ethical challenges arising from pandemic research and how involving consumers and the community could enable resolution of such issues.

Gains Across WHO Dimensions of Function After Robot-Based Therapy in Stroke Subjects

BACKGROUND

Studies examining the effects of therapeutic interventions after stroke often focus on changes in loss of body function/structure (impairment). However, improvements in activities limitations and participation restriction are often higher patient priorities, and the relationship that these measures have with loss of body function/structure is unclear.

OBJECTIVE

This study measured gains across WHO International Classification of Function (ICF) dimensions and examined their interrelationships.

METHODS

Subjects were recruited 11 to 26 weeks after hemiparetic stroke. Over a 3-week period, subjects received 12 sessions of intensive robot-based therapy targeting the distal arm. Each subject was assessed at baseline and at 1 month after end of therapy.

RESULTS

At baseline, subjects (n = 40) were 134.7 ± 32.4 (mean ± SD) days poststroke and had moderate-severe arm motor deficits (arm motor Fugl-Meyer score of 35.6 ± 14.4) that were stable. Subjects averaged 2579 thumb movements and 1298 wrist movements per treatment session. After robot therapy, there was significant improvement in measures of body function/structure (Fugl-Meyer score) and activity limitations (Action Research Arm Test, Barthel Index, and Stroke Impact Scale-Hand), but not participation restriction (Stroke Specific Quality of Life Scale). Furthermore, while the degree of improvement in loss of body function/structure was correlated with improvement in activity limitations, neither improvement in loss of body function/structure nor improvement in activity limitations was correlated with change in participation restriction.

CONCLUSIONS

After a 3-week course of robotic therapy, there was improvement in body function/structure and activity limitations but no reduction in participation restriction.

Evaluation of a structured preceptorship programme

Preceptorship is a period in which newly qualified staff nurses receive support from an experienced nurse to smooth their transition into the service. District nurses (DNs) from the authors' trust informally expressed the need for a better transition between the completion of district nursing education and entry into the workforce. Hence, a structured preceptorship programme was developed and delivered. This article describes this service initiative and its evaluation by preceptors (n=14) and preceptees (newly qualified DNs; n=13). Both groups valued having a structured preceptorship programme. Preceptees agreed that having a named preceptor was very important, and preceptors felt that the role which they played was rewarding. Both groups felt that the role of the DN was a specialist role and that the preceptorship programme helped to support newly qualified staff make the transition into qualified DNs, clinical team leaders and, ultimately, caseload holders. A large-scale study of DN practice is required to develop a national consensus on the structure and content of preceptorship programmes for district nursing.

Abstract WP193: A Pilot Study of Expanded Home-Based Telerehabilitation After Stroke

Introduction: High doses of activity-based rehabilitation therapy help but many patients do not receive this, e.g., due to access, cost, and low compliance. Home-based telerehabilitation (TR) can address these issues. A prior study found 6 weeks of TR targeting arm motor deficits after stroke comparably efficacious vs. therapy delivered in-clinic. Here, we evaluated a program expanded in TR dose and scope.

Methods: Adults with stroke and arm motor deficits saw a licensed OT/PT who performed a live exam then supervised home-based TR (6 days/week, 1 hour/day) through games, exercises, and education. New features examined herein included (a) extending therapy to 12 weeks, (b) treating both arm and leg motor deficits, (c) augmented reality games, (d) wireless smart devices, (e) ingesting a daily experimental (placebo) pill, (f) using functional objects, (g) evaluating social networks, and (h) automated actionable reports.

Results: Patients (n=13) were median age 61 [IQR=52-65.5], and 129 [52-486] days post-stroke. Patients initiated therapy on 79.9% of the 72 assigned days and completed >30 min on 65.7% of days, for a 12-week total therapy dose of 50.4 [33.3 - 56.7] hours. Non-compliant days during weeks 7-12 were double those of weeks 1-6. Modified Rankin scores improved by 1 level in 6/13 patients, 3 of whom were > 3month post-stroke. Fugl-Meyer motor scores increased by 6 [2.5-12.5] points in the arm and 1 [-0.5 - 5] point in the leg, mainly in weeks 1-6. Geriatric Depression Scale scores fell from 3 [1-5] at baseline (3/13 with depression) to 1 [0-4] (0/13 with depression) at week 12. Augmented reality gaming and functional objects were well received. Communication with smart devices was challenging. The experimental pill was taken, with photo verification, on 90.9% of days. Enrollees had large social networks. Automatic reports reliably notified study personnel when compliance was low or behavioral scores were concerning.

Conclusions: High doses of home-based TR targeting arm and leg motor deficits are feasible and improve functional outcomes, motor deficits, and mood. The current system automates experimental pill ingestion and actionable reports to clinicians. Compliance declined over time, suggesting the need for novel approaches to extended periods of TR.

A qualitative study on user acceptance of a home-based stroke telerehabilitation system

Objective: This paper reports a qualitative study of a home-based stroke telerehabilitation system. The telerehabilitation system delivers treatment sessions in the form of daily guided rehabilitation games, exercises, and stroke education in the patient's home. The aims of the current report are to investigate patient perceived benefits of and barriers to using the telerehabilitation system at home.Methods: We used a qualitative study design that involved in-depth semi-structured interviews with 13 participants who were patients in the subacute phase after stroke and had completed a six-week intervention using the home-based telerehabilitation system. Thematic analysis was conducted to analyze the data.Results: Participants mostly reported positive experiences with the telerehabilitation system. Benefits included observed improvements in limb functions, cognitive abilities, and emotional well-being. They also perceived the system easy to use due to the engaging experience and the convenience of conducting sessions at home. Meanwhile, participants pointed out the importance of considering technical support and physical environment at home. Further, family members' support helped them sustain in their rehabilitation. Finally, adjusting difficulty levels and visualizing patients' rehabilitation progress might help them in continued use of the telerehabilitation system.Conclusion: Telerehabilitation systems can be used as an efficient and user-friendly tool to deliver home-based stroke rehabilitation that enhance patients' physical recovery and mental and social-emotional wellbeing. Such systems need to be designed to offer engaging experience, display of recovery progress, and flexibility of schedule and location, with consideration of facilitating and social factors.

Efficacy of Home-Based Telerehabilitation vs In-Clinic Therapy for Adults After Stroke: A Randomized Clinical Trial

Importance

Many patients receive suboptimal rehabilitation therapy doses after stroke owing to limited access to therapists and difficulty with transportation, and their knowledge about stroke is often limited. Telehealth can potentially address these issues.

Objectives

To determine whether treatment targeting arm movement delivered via a home-based telerehabilitation (TR) system has comparable efficacy with dose-matched, intensity-matched therapy delivered in a traditional in-clinic (IC) setting, and to examine whether this system has comparable efficacy for providing stroke education.

Design, Setting, and Participants

In this randomized, assessor-blinded, noninferiority trial across 11 US sites, 124 patients who had experienced stroke 4 to 36 weeks prior and had arm motor deficits (Fugl-Meyer [FM] score, 22-56 of 66) were enrolled between September 18, 2015, and December 28, 2017, to receive telerehabilitation therapy in the home (TR group) or therapy at an outpatient rehabilitation therapy clinic (IC group). Primary efficacy analysis used the intent-to-treat population.

Interventions

Participants received 36 sessions (70 minutes each) of arm motor therapy plus stroke education, with therapy intensity, duration, and frequency matched across groups.

Main Outcomes and Measures

Change in FM score from baseline to 4 weeks after end of therapy and change in stroke knowledge from baseline to end of therapy.

Results

A total of 124 participants (34 women and 90 men) had a mean (SD) age of 61 (14) years, a mean (SD) baseline FM score of 43 (8) points, and were enrolled a mean (SD) of 18.7 (8.9) weeks after experiencing a stroke. Among those treated, patients in the IC group were adherent to 33.6 of the 36 therapy sessions (93.3%) and patients in the TR group were adherent to 35.4 of the 36 assigned therapy sessions (98.3%). Patients in the IC group had a mean (SD) FM score change of 8.36 (7.04) points from baseline to 30 days after therapy (P < .001), while those in the TR group had a mean (SD) change of 7.86 (6.68) points (P < .001). The covariate-adjusted mean FM score change was 0.06 (95% CI, -2.14 to 2.26) points higher in the TR group (P = .96). The noninferiority margin was 2.47 and fell outside the 95% CI, indicating that TR is not inferior to IC therapy. Motor gains remained significant when patients enrolled early (<90 days) or late (≥90 days) after stroke were examined separately.

Conclusions and Relevance

Activity-based training produced substantial gains in arm motor function regardless of whether it was provided via home-based telerehabilitation or traditional in-clinic rehabilitation. The findings of this study suggest that telerehabilitation has the potential to substantially increase access to rehabilitation therapy on a large scale.

Trial Registration

ClinicalTrials.gov identifier: NCT02360488.

Predicting Gains With Visuospatial Training After Stroke Using an EEG Measure of Frontoparietal Circuit Function

The heterogeneity of stroke prompts the need for predictors of individual treatment response to rehabilitation therapies. We previously studied healthy subjects with EEG and identified a frontoparietal circuit in which activity predicted training-related gains in visuomotor tracking. Here we asked whether activity in this same frontoparietal circuit also predicts training-related gains in visuomotor tracking in patients with chronic hemiparetic stroke. Subjects (n = 12) underwent dense-array EEG recording at rest, then received 8 sessions of visuomotor tracking training delivered via home-based telehealth methods. Subjects showed significant training-related gains in the primary behavioral endpoint, Success Rate score on a standardized test of visuomotor tracking, increasing an average of 24.2 ± 21.9% (p = 0.003). Activity in the circuit of interest, measured as coherence (20–30 Hz) between leads overlying ipsilesional frontal (motor cortex) and parietal lobe, significantly predicted training-related gains in visuomotor tracking change, measured as change in Success Rate score (r = 0.61, p = 0.037), supporting the main study hypothesis. Results were specific to the hypothesized ipsilesional motor-parietal circuit, as coherence within other circuits did not predict training-related gains. Analyses were repeated after removing the four subjects with injury to motor or parietal areas; this increased the strength of the association between activity in the circuit of interest and training-related gains. The current study found that (1) Eight sessions of training can significantly improve performance on a visuomotor task in patients with chronic stroke, (2) this improvement can be realized using home-based telehealth methods, (3) an EEG-based measure of frontoparietal circuit function predicts training-related behavioral gains arising from that circuit, as hypothesized and with specificity, and (4) incorporating measures of both neural function and neural injury improves prediction of stroke rehabilitation therapy effects.

Abstract TP141: Feasibility of Online Training and Certification for the Fugl-Meyer Motor Assessment in Stroke Recovery Trials

Introduction: Standardized measurement of clinical outcomes across sites and over time is critical to clinical trials. Barriers to outcome measure training include availability of standardized materials and time to train, plus wide geographic distribution of trial personnel. To address these, an online training and certification program based on NIHSS testing was developed and implemented for the Fugl Meyer Motor Assessment (FMMA) in support of multisite stroke recovery trials.

Methods: This program includes Fugl Meyer Arm (FMA) and Leg (FML) components, runs on a web host, and is based on a valid, reliable approach to FMMA testing known to decrease variance in scoring (See et al, NNR, 2013;27:732-741). The website hosts training courses, reference manuals, video patient cases for formal certification testing plus 3 rounds of recertification; each round has 2 separate patients. A passing score of 90% is required. After each course, feedback is given.

Results: This program has served as the primary training, certification, and recertification mechanism for 4 multisite recovery trials, including 1 NIH-funded US trial and 3 industry-sponsored international trials. Three trials certify on both FMA and FML, and 1 on FMA only, as primary endpoint. Evaluators are recertified every 4-6 months. The 299 clinicians from 5 countries registered include PT/OT (n=136), MD (n=37), and RN/NP/PA (n=15). For FMA training, 299 persons have registered and 197 completed. For the first round of FMA certification, 267 have registered and 171 passed (mean 1.89 attempts to pass). For the second FMA (first recertification), 78 registered and 65 passed. The passing rate increased with successive rounds of recertification. Similar numbers have been achieved for FML training, certification, and recertification.

Conclusions: The FMMA has established value for capturing treatment-related motor gains in stroke recovery trials. The current online training program is efficient and effective for training, certifying, and recertifying examiners in arm and leg FMMA. Clinical trial assessors training with this program can be expected to provide more accurate and less variable FMMA scores, which increases statistical power, reduces sample sizes, and reduces the cost of clinical trials.

Abstract TP154: A Qualitative Study on a Telehealth System for Home-Based Stroke Rehabilitation

Purpose: This abstract reports a qualitative study on a home-based stroke telerehabilitation system. The telerehabilitation system delivers treatment sessions in the form of daily guided rehabilitation games, exercises, and stroke education at the patient’s home. Therapists examine patients then establish regular videoconferences with them via the system to discuss their progress, provide feedback, and adjust treatment. The aims of this study were to investigate patients’ general impressions about the benefits of and barriers to using the telerehabilitation system at home.

Methods: We used a qualitative study design that involved in-depth semi-structured interviews with 10 participants who had completed a 6-week intervention using the telerehabilitation system. Thematic analysis was conducted using the grounded theory approach.

Results: Participants mostly reported positive experiences with the telerehabilitation system. Benefits included observed improvements in limb functions and provision of an outlet for mental tension and anxiety. They mainly valued the following four merits of the system: engaging game experience, flexibility in time and location in using the system, having the therapists accountable, and having less burden on caregivers. In particular, all participants rated highly their experience using the videoconference capability, which provided a channel for therapists to observe, correct, and provide feedback and encouragement to patients. Most patients expressed that they established a personal connection with the therapist through use of the telerehabilitation system. By doing so, they felt less isolated and more positive and connected. Finally, communicating with therapists three times a week also held patients accountable for completing the exercises. Barriers to system use were all logistics-related, such as the lack of physical space at home, which impeded effective use, and poor internet connection at home.

Conclusions: The telerehabilitation system studied provides patients with home-based access to games, exercises, education, and therapists. Based on participants’ qualitative feedback, it is a promising tool to deliver stroke rehabilitation therapies effectively and remotely to patients at home.

Validity of Robot-Based Assessments of Upper Extremity Function

OBJECTIVE

To examine the validity of 5 robot-based assessments of arm motor function poststroke.

DESIGN

Cross-sectional study.

SETTING

Outpatient clinical research center.

PARTICIPANTS

Volunteer sample of participants (N=40; age, >18y; 3-6mo poststroke) with arm motor deficits that had reached a stable plateau.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Clinical standards included the arm motor domain of the Fugl-Meyer Assessment (FMA) and 5 secondary motor outcomes: hand/wrist subsection of the arm motor domain of the FMA, Action Research Arm Test, Box and Block test (BBT), hand motor subscale of the Stroke Impact Scale Version 2.0, and Barthel Index. Robot-based assessments included wrist targeting, finger targeting, finger movement speed, reaction time, and a robotic version of the BBT. Anatomical measures included percent injury to the corticospinal tract (CST) and extent of injury of the hand region of the primary motor cortex obtained from magnetic resonance imaging.

RESULTS

Participants had moderate to severe impairment (arm motor domain of the FMA scores, 35.6±14.4; range, 13.5-60). Performance on the robot-based tests, including speed (r=.82; P<.0001), wrist targeting (r=.72; P<.0001), and finger targeting (r=.67; P<.0001), correlated significantly with the arm motor domain of the FMA scores. Wrist targeting (r=.57-.82) and finger targeting (r=.49-.68) correlated significantly with all 5 secondary motor outcomes and with percent CST injury. The robotic version of the BBT correlated significantly with the clinical BBT but was less prone to floor effects. Robot-based assessments were comparable to the arm motor domain of the FMA score in relation to percent CST injury and superior in relation to extent of injury to the hand region of the primary motor cortex.

CONCLUSIONS

The present findings support using a battery of robot-based methods for assessing the upper extremity motor function in participants with chronic stroke.

Abstract 11: Targeted Training of a Motor-parietal Circuit Improves Its Behavioral Output

Introduction: Emerging brain mapping methods measure function of individual brain circuits and have the potential to predict a patient’s gains and needs in the context of stroke rehabilitation. We recently described a motor-parietal circuit underlying visuomotor tracking and defined an EEG coherence measure (reflecting connectivity) that predicts visuomotor learning. Here we test the hypothesis that this EEG metric predicts visuomotor learning after stroke.

Methods: After baseline dense-array resting EEG, patients with chronic hemiparetic stroke were provided with a home-based gaming system. During 9 half-hour training sessions, patients played games in which the stroke-affected arm tracked objects moving on the tabletop. Games were implemented using augmented reality, which we have found has advantages for motor training and in which virtual objects are projected into the real world and modified during game play.

Results: Subjects (n=12) had affected arm Box&Blocks score of 15±12 and were 35±26 mo post-stroke. Visuomotor tracking improved significantly: on a standardized visuomotor test using the gaming system, scores increased from 60.5±11.5% to 74.0±3.2% (p=0.003). Gains were specific, as other behaviors were unchanged. Individual gains in visuomotor tracking score were predicted by the EEG connectivity metric from our prior study, coherence between leads overlying ipsilesional primary motor cortex (M1i) and ipsilesional lateral parietal region in the high beta (20-30 Hz) range, with higher connectivity predicting greater visuomotor tracking gains (r=0.61, p=0.037). This too was specific, as connectivity between M1i and other brain areas did not predict gains. Secondary analysis found that baseline visuomotor tracking scores correlated with several EEG connectivity measures, all inversely and all between M1i and contralesional regions.

Conclusions: We found that (1) training that targets a specific brain circuit improves behavioral output of that circuit, and (2) an EEG measure of brain connectivity within that circuit predicts these behavioral gains--both with specificity. This approach may be useful for many neural circuits and their respective rehabilitation-related behaviors.

Early Rehabilitation in the Medical and Surgical Intensive Care Units for Patients With and Without Mechanical Ventilation: An Interprofessional Performance Improvement Project

BACKGROUND

Most early mobility studies focus on patients on mechanical ventilation and the role of physical and occupational therapy. This Performance Improvement Project (PIP) project examined early mobility and increased intensity of therapy services on patients in the intensive care unit (ICU) with and without mechanical ventilation. In addition, speech-language pathology rehabilitation was added to the early mobilization program.

OBJECTIVE

We sought to assess the efficacy of early mobilization of patients with and without mechanical ventilation in the ICU on length of stay (LOS) and patient outcomes and to determine the financial viability of the program.

DESIGN

PIP. Prospective data collection in 2014 (PIP) compared with a historical patient population in 2012 (pre-PIP).

SETTING

Medical and surgical ICUs of a Level 2 trauma hospital.

PATIENTS

There were 160 patients in the PIP and 123 in the pre-PIP.

INTERVENTIONS

Interprofessional training to improve collaboration and increase intensity of rehabilitation therapy services in the medical and surgical intensive care units for medically appropriate patients.

MEASUREMENTS

Demographics; intensity of service; ICU and hospital LOS; medications; pain; discharge disposition; functional mobility; and average cost per day were examined.

MAIN RESULTS

Rehabilitation therapy services increased from 2012 to 2014 by approximately 60 minutes per patient. The average ICU LOS decreased by almost 20% from 4.6 days (pre-PIP) to 3.7 days (PIP) (P = .05). A decrease of over 40% was observed in the floor bed average LOS from 6.0 days (pre-PIP) to 3.4 days (PIP) (P < .01). An increased percentage of PIP patients, 40.5%, were discharged home without services compared with 18.2% in the pre-PIP phase (P < .01). Average cost per day in the ICU and floor bed decreased in the PIP group, resulting in an annualized net cost savings of $1.5 million.

CONCLUSIONS

The results of the PIP indicate that enhanced rehabilitation services in the ICU is clinically feasible, results in improved patient outcomes, and is fiscally sound. Most early mobility studies focus on patients on mechanical ventilation. The results of this PIP project demonstrate that there are significant benefits to early mobility and increased intensity of therapy services on ICU patients with and without mechanical ventilation. Benefits include reduced hospitalization LOS, decreased health care costs, and decreased need for postacute care services.

LEVEL OF EVIDENCE

III.

Choice of Human-Computer Interaction Mode in Stroke Rehabilitation

BACKGROUND AND OBJECTIVE

Advances in technology are providing new forms of human-computer interaction. The current study examined one form of human-computer interaction, augmented reality (AR), whereby subjects train in the real-world workspace with virtual objects projected by the computer. Motor performances were compared with those obtained while subjects used a traditional human-computer interaction, that is, a personal computer (PC) with a mouse.

METHODS

Patients used goal-directed arm movements to play AR and PC versions of the Fruit Ninja video game. The 2 versions required the same arm movements to control the game but had different cognitive demands. With AR, the game was projected onto the desktop, where subjects viewed the game plus their arm movements simultaneously, in the same visual coordinate space. In the PC version, subjects used the same arm movements but viewed the game by looking up at a computer monitor.

RESULTS

Among 18 patients with chronic hemiparesis after stroke, the AR game was associated with 21% higher game scores (P = .0001), 19% faster reaching times (P = .0001), and 15% less movement variability (P = .0068), as compared to the PC game. Correlations between game score and arm motor status were stronger with the AR version.

CONCLUSIONS

Motor performances during the AR game were superior to those during the PC game. This result is due in part to the greater cognitive demands imposed by the PC game, a feature problematic for some patients but clinically useful for others. Mode of human-computer interface influences rehabilitation therapy demands and can be individualized for patients.

Connectivity measures are robust biomarkers of cortical function and plasticity after stroke

Valid biomarkers of motor system function after stroke could improve clinical decision-making. Electroencephalography-based measures are safe, inexpensive, and accessible in complex medical settings and so are attractive candidates. This study examined specific electroencephalography cortical connectivity measures as biomarkers by assessing their relationship with motor deficits across 28 days of intensive therapy. Resting-state connectivity measures were acquired four times using dense array (256 leads) electroencephalography in 12 hemiparetic patients (7.3 ± 4.0 months post-stroke, age 26-75 years, six male/six female) across 28 days of intensive therapy targeting arm motor deficits. Structural magnetic resonance imaging measured corticospinal tract injury and infarct volume. At baseline, connectivity with leads overlying ipsilesional primary motor cortex (M1) was a robust and specific marker of motor status, accounting for 78% of variance in impairment; ipsilesional M1 connectivity with leads overlying ipsilesional frontal-premotor (PM) regions accounted for most of this (R(2) = 0.51) and remained significant after controlling for injury. Baseline impairment also correlated with corticospinal tract injury (R(2) = 0.52), though not infarct volume. A model that combined a functional measure of connectivity with a structural measure of injury (corticospinal tract injury) performed better than either measure alone (R(2) = 0.93). Across the 28 days of therapy, change in connectivity with ipsilesional M1 was a good biomarker of motor gains (R(2) = 0.61). Ipsilesional M1-PM connectivity increased in parallel with motor gains, with greater gains associated with larger increases in ipsilesional M1-PM connectivity (R(2) = 0.34); greater gains were also associated with larger decreases in M1-parietal connectivity (R(2) = 0.36). In sum, electroencephalography measures of motor cortical connectivity-particularly between ipsilesional M1 and ipsilesional premotor-are strongly related to motor deficits and their improvement with therapy after stroke and so may be useful biomarkers of cortical function and plasticity. Such measures might provide a biological approach to distinguishing patient subgroups after stroke.

Abstract 5: Role of Contralesional Hemisphere during Paretic Hand Movement Differs Based on Level of Motor Impairment

Introduction: Paretic hand movements after stroke often correspond to activation in both the ipsilesional and contralesional hemispheres. Changes in intra- and interhemispheric connectivity have been reported but most studies have focused on individuals with limited motor impairment. The purpose of this pilot study was to examine connectivity between motor regions during paretic hand movement in a population with a range of motor impairment after stroke.

Methods: Seventeen right-hand dominant individuals with hemispheric stroke (age 58.7±13.9; UE FM 34.3±12.3; days post-stroke 154.6±101.8) underwent functional MRI during paretic hand grasp/release. Data were extracted from 4 regions of interest (ROI) bilaterally: M1, dorsal premotor (PMd), supplementary motor (SMA), and visual association cortices. No participant had lesions in these cortical areas. These ROIs were included in a DCM analysis that focused on intrinsic connectivity during hand movement. Bayesian model selection was used to determine the optimal model from a set of bilateral (B), ipsilesional (IL), and contralesional (CL) models; Bayesian model averaging was used to extract coupling parameters across models.

Results: Overall, individuals activated a bilateral network of motor regions during movement that included M1, PMd, SMA, basal ganglia, and cerebellum. There was variability between subjects as to the model that best fit the data: B for 3 subjects, IL for 6 subjects, and CL for 8 subjects. These three groups differed significantly in median UEFM scores ( p =0.021; B=50, IL=34, CL=22) and number of blocks moved with the paretic hand in the Box & Blocks ( p =0.03; B=35, IL=8, CL=0). Additionally, the direction and magnitude of M1-M1 coupling differed between the groups ( p <0.016): CL M1 had a facilitatory influence on IL M1 in the B group (median=0.112) and CL group (0.469) but an inhibitory influence in the IL group (-0.524).

Conclusions: Connectivity analysis revealed that the CL hemisphere plays a facilitatory role in some individuals and an inhibitory role in others that is related to level of motor impairment. Such variability in the role of the CL may have an impact on response to interventions aimed at altering communication between hemispheres during movement.

Neural function, injury, and stroke subtype predict treatment gains after stroke

OBJECTIVE

This study was undertaken to better understand the high variability in response seen when treating human subjects with restorative therapies poststroke. Preclinical studies suggest that neural function, neural injury, and clinical status each influence treatment gains; therefore, the current study hypothesized that a multivariate approach incorporating these 3 measures would have the greatest predictive value.

METHODS

Patients 3 to 6 months poststroke underwent a battery of assessments before receiving 3 weeks of standardized upper extremity robotic therapy. Candidate predictors included measures of brain injury (including to gray and white matter), neural function (cortical function and cortical connectivity), and clinical status (demographics/medical history, cognitive/mood, and impairment).

RESULTS

Among all 29 patients, predictors of treatment gains identified measures of brain injury (smaller corticospinal tract [CST] injury), cortical function (greater ipsilesional motor cortex [M1] activation), and cortical connectivity (greater interhemispheric M1-M1 connectivity). Multivariate modeling found that best prediction was achieved using both CST injury and M1-M1 connectivity (r(2) = 0.44, p = 0.002), a result confirmed using Lasso regression. A threshold was defined whereby no subject with >63% CST injury achieved clinically significant gains. Results differed according to stroke subtype; gains in patients with lacunar stroke were best predicted by a measure of intrahemispheric connectivity.

INTERPRETATION

Response to a restorative therapy after stroke is best predicted by a model that includes measures of both neural injury and function. Neuroimaging measures were the best predictors and may have an ascendant role in clinical decision making for poststroke rehabilitation, which remains largely reliant on behavioral assessments. Results differed across stroke subtypes, suggesting the utility of lesion-specific strategies.

Abstract 229: Development of a Conditional Knockout of Cholesterol Synthesis in the Mouse

Dhcr24 (3β-hydroxysteroid-Δ24 reductase) is responsible for reducing the C24-C25 double bond in sterol intermediates of cholesterol and this step is necessary to synthesize cholesterol. In humans, mutations in the Dhcr24 gene cause desmosterolosis (OMIM #602398), characterized by severe developmental abnormalities and elevated levels of desmosterol in plasma and tissue. The first case was reported in 1998 when a premature infant died shortly after birth, had elevated levels of desmosterol and phenotypic abnormalities. Although initially reported as a ‘cholesterol-free mouse’ in Science, the global Dhcr24 knockout mouse shows neonatal lethality within 10h of birth, a finding reproduced in many different laboratories, despite sharing the original knockout mouse.

We now report a conditional knockout model using the LoxP-cre deletion system and show proof-of-principle by studying effects Dhcr24 deletion in the liver.

A multimodal approach to understanding motor impairment and disability after stroke

Many different measures have been found to be related to behavioral outcome after stroke. Preclinical studies emphasize the importance of brain injury and neural function. However, the measures most important to human outcomes remain uncertain, in part because studies often examine one measure at a time or enroll only mildly impaired patients. The current study addressed this by performing multimodal evaluation in a heterogeneous population. Patients (n = 36) with stable arm paresis 3-6 months post-stroke were assessed across 6 categories of measures related to stroke outcome: demographics/medical history, cognitive/mood status, genetics, neurophysiology, brain injury, and cortical function. Multivariate modeling identified measures independently related to an impairment-based outcome (arm Fugl-Meyer motor score). Analyses were repeated (1) identifying measures related to disability (modified Rankin Scale score), describing independence in daily functions and (2) using only patients with mild deficits. Across patients, greater impairment was related to measures of injury (reduced corticospinal tract integrity) and neurophysiology (absence of motor evoked potential). In contrast, (1) greater disability was related to greater injury and poorer cognitive status (MMSE score) and (2) among patients with mild deficits, greater impairment was related to cortical function (greater contralesional motor/premotor cortex activation). Impairment after stroke is most related to injury and neurophysiology, consistent with preclinical studies. These relationships vary according to the patient subgroup or the behavioral endpoint studied. One potential implication of these results is that choice of biomarker or stratifying variable in a clinical stroke study might vary according to patient characteristics.

Abstract T MP42: The Use of Voxel-Based Lesion Symptom Mapping to Relate Lesion Location to Motor Performance in Chronic Stroke Survivors

Background and Purpose: We used voxel-based lesion symptom mapping (VLSM) to determine the relationship between lesion location and performance on upper extremity behavioral outcome measures post-stroke. We hypothesized that a lesion within the upper extremity region of the primary motor cortex would correlate with poorer hand motor outcome measures.

Methods: Thirty-six chronic stroke survivors with upper extremity motor deficits who underwent 3 weeks of hand/wrist robotic therapy were included in the study. Behavioral motor outcome measures included: Fugl-Meyer Arm (FMA) Test, Action Research Arm Test (ARAT), and Box & Blocks Test (BB). Anatomical imaging included a high-resolution T1-weighted volumetric scan and a T2-weighted scan. Lesioned areas were manually traced using MRIcron; stroke masks were flipped to left and binarized. All of the subjects’ T1-weighted images were transformed to Montreal Neurological Institute (MNI) standardized stereotaxic space. Data were analyzed using the non-parametric mapping (NPM) software package in MRIcron with the Brunner-Munzel test set at 1,000 permutations and a 10% threshold. The threshold for the overlap between low behavioral scores and related brain regions was set at α= 0.01.

Results: Lesions in the inferior frontal gyrus and underlying white matter and the posterior limb of the internal capsule (PLIC) correlated with poorer motor outcomes on the FMA and ARAT, indicating a degree of anatomical overlap between impairment and activity levels of upper extremity motor performance. Lesions of the premotor area also correlated with poorer ARAT outcomes, whereas lesions of the middle frontal gyrus and underlying white matter correlated with poorer performance on the BB, reflecting the role that motor planning plays in those activities.

Conclusions: Voxel-Based Symptom Mapping adds a new dimension in clarifying the specific lesion location associated with dexterous motor function post-stroke. Activity vs. impairment deficits relate to lesions in anatomical areas involved in motor planning vs. those involved in movement execution.

Abstract 148: Cortical Connectivity is a Powerful Predictor of Motor Recovery in Chronic Stroke

Introduction: Refinement of biomarkers and predictors of treatment response could greatly benefit restorative stroke therapeutics. The current study examined the performance of established biomarker/predictor measures in patients undergoing 4 weeks of therapy, and also examined performance of dense array EEG (d-EEG) measures of cortical connectivity.

Methods: Twelve adults (mean age=54.0 ± 16.6 years) with chronic stroke and hemiparesis (Fugl-Meyer (FM) score=39 ± 12, range 23-56, max 66) underwent a baseline 3 minute resting dEEG recording (256 leads) as well as a 3T MRI scan, then received 4 weeks of telerehabilitation therapy. For dEEG measurement of cortical connectivity, mean coherence was derived for the high beta (20-30 Hz) frequency band, then partial least squares (PLS) regression was used to relate resting-state mean beta coherence to: (1) baseline impairment (FM score), and (2) improvement (change in FM across 4 weeks of therapy). Infarct volume and % corticospinal tract (CST) injury, measured on MRI scans, were also analyzed.

Results: Arm motor status improved across the 4 weeks of therapy (FM change=4.5 ± 2.6, p=0.0001). Regarding biomarkers, CST injury correlated with baseline FM (R2=0.52, p=0.008), but infarct volume and age did not (p>0.05). Resting-state dEEG beta coherence correlated with baseline FM (R2=0.95); adding infarct volume and CST injury to the dEEG findings did not improve predictive strength. Regarding predictors, infarct volume, CST injury, age, and baseline FM each did not predict change in FM across the 4 wk of therapy (p>0.05). However, resting-state beta coherence, using a leave-one-out and predict validation procedure on the pre-therapy dEEG, predicted change in FM score with R2=0.74; adding infarct volume, CST injury, and baseline FM to the dEEG findings again did not improve prediction.

Conclusions: The dEEG measures of cortical connectivity were strong correlates of baseline status and excellent predictors of behavioral improvement across 4 weeks of therapy. These dEEG measures compared favorably with established behavioral, demographic, and radiological measures. Resting state dEEG is a rapid, simple, safe method for studying brain function that performs excellently as a biomarker and as a predictor.

Abstract T MP40: A Home-Based Telerehabilitation System for Patients With Stroke

Evidence suggests that greater duration and intensity of rehabilitation therapy improves outcomes for patients with stroke. Delivery of care is often limited, however, e.g., due to systems of care delivery, cost, rural location, or difficulty travelling. The current study addressed this unmet need by examining the feasibility of a home-based telerehabilitation system. Entry criteria included age >18 yrs, 12-26 wk post stroke, and arm motor deficits (Fugl-Meyer (FM) score 22-55) that were stable. Each subject received 28 d of daily home-based telerehabilitation using a fixed system that we delivered/assembled. Each day consisted of 1 structured hour (testing, BP check, individualized exercises and games, and stroke prevention education) plus up to 1 hour of free play on dozens of games. Each week, subjects had a 1 videoconference with a licensed therapist and 1 with a research assistant; subjects could also phone the lab for technical support if needed. Enrollees were 54±17 yr (mean±SD), 6M/6F, with baseline FM=39±12 (range 23-55). Compliance was excellent, with subjects engaging in therapy 329 of 336 (97.9%) assigned days. Arm motor status improved (FM change 4.8±3.8 points from baseline to 1 mo post-therapy, p=0.0015). Although scores on tests of computer literacy declined with age (r = -0.90 to -0.92, p<0.0001), as expected, the arm motor gains derived from use of this system did not vary with age. The stroke education module was associated with significant gains in stroke prevention knowledge. BP was recorded by the patient, and results automatically transmitted to lab, on 97.9% of assigned days. Therapist videoconferences detected PHQ-2 scores consistent with depression in 3/12 patients. Therapists were able to review patient performances and upload revised therapy settings to the patient’s home system without difficulty at any time of day. Results of this pilot study support the utility of a home-based system to effectively deliver telerehabilitation, improve patient education, screen for complications of stroke, and as well as to provide a means for patient interaction with medical personnel. The use of a computer-based interface offers many opportunities to monitor and improve the health of patients after stroke.

Abstract T MP43: Utility of Augmented Reality in Relation to Virtual Reality in Stroke Rehabilitation

Introduction: Virtual Reality (VR) has been found useful for numerous rehabilitation applications, but has some intrinsic constraints such as the need for a visuospatial transformation when guiding movements. Augmented Reality (AR) is a new approach to human-computer interaction that enables patients to interact directly with virtual objects. The current study compared AR and VR in a stroke rehabilitation setting.

METHODS: The Fruit Ninja game simulates a rehab setting by having subjects perform repeated goal-directed wrist/hand reaching tasks. Subjects held a cup-shaped color-marker in the paretic hand, then reached for a virtual fruit target that sliced in 2 when reached. This game was implemented in both AR and VR settings, with identical movement demands across the two. The target plus real-time visual feedback on hand movements were provided by a computer monitor in VR, and by a projection onto a tabletop in AR. After undergoing baseline assessments (arm motor Fugl-Meyer scale (FMA) and Box and Blocks (B&B)), 10 patients with hemiparetic stroke >6 mo prior and age >18 yr played three 1-min rounds each of the AR and VR games; 4 other subjects who were unable to hold the color-marker object were excluded from current analysis.

RESULTS: Of the 10 patients, age = 59±10 yr (mean±SD), FMA score = 57±11 (range 31-66), Hand/Wrist FMA subscore = 22±3 (range 15-24), and B&B score = 41±13 (range 16-58). When playing the exact same Fruit Ninja game, all 10 patients scored significantly (p<0.0001) higher in the AR setting (60±9 targets, range 48-78) as compared to the VR setting (48±8 targets, range 37-64 setting. Also, AR scores were stronger correlates of FM Hand/Wrist (rho=0.68, p<0.04) and B&B scores (rho=0.70, p<0.03) than were VR scores.

CONCLUSIONS: This study shows promising results with use of Augmented Reality in a patient-computer interface. Results also suggest advantages as compared to use of a Virtual Reality approach, possibly due to the fact that moving the hand requires a visuospatial transform in the VR setting but not in the AR setting. Compared to VR, AR scores were higher and correlated better with clinical scores, suggesting great potential for the use of Augmented Reality in a patient-computer interface during stroke rehabilitation.

Abstract T MP44: Different Predictors of Treatment Gains in Lacunar and Non-lacunar Stroke

Introduction: Numerous predictors of treatment-induced behavioral gains after stroke have been identified. However, only a few types of predictors have generally been examined at a time. The current study examined multiple categories of established predictors in parallel among patients enrolled in a motor therapy study, hypothesizing that brain injury and function are of greatest predictive value. Furthermore, given that clinical relationships often differ according to stroke pathophysiology, the hypothesis was also tested that predictors of treatment gains vary according to stroke subtype.

METHODS: Patients with age>18 yr, stable arm paresis, and stroke 11-26 wks prior were enrolled in a study (NCT01244243) that provided 3 weeks of standardized robotic arm therapy. The primary outcome measure was change in Fugl-Meyer (FM) and Action Research Arm Test (ARAT) scores. A total of 6 categories of baseline assessments were evaluated as potential predictors of treatment gains: [1] demographics/history, [2] behavior, [3] genetics, [4] neurophysiology (TMS), [5] brain injury (3T MRI), and [6] brain function (3T fMRI). For each category, the strongest bivariate predictor of gains (when significant) was advanced into a multivariate model.

RESULTS: At baseline, the 29 patients had substantial motor deficits (FM=36±15), medium-sized infarcts (33±48cc; 8 lacunar, 21 non-lacunar), and were 4.3 months post-stroke. Patients improved significantly (p<0.0005) on the FM (3.7±3.5) and ARAT (4.1±6.3) scores. In non-lacunar stroke, extent of corticospinal tract injury and baseline behavior survived as predictors of treatment gains in the multivariate model (r=0.60, p=0.02). In lacunar stroke, the model found that extent of activation within ipsilesional primary motor cortex was the sole predictor of gains (r=0.79, p=0.02).

CONCLUSIONS: Measures of brain injury, brain function, and behavior are the strongest predictors of arm motor gains among patients in the early phase of chronic stroke. Different factors predict gains across stroke subtypes. Current results may be useful for patient selection in a clinical trial setting, where effective stratification can reduce variance and increase study power.

Computed tomographic measures of airway morphology in smokers and never-smoking normals

Bronchial wall area percent (WA% = 100 × wall area/total bronchial cross sectional area) is a standard computed tomographic (CT) measure of central airway morphology utilized in smokers with chronic obstructive pulmonary disease (COPD). Although it provides significant clinical correlations, the range of reported WA% is narrow. This suggests limited macroscopic change in response to smoking or that remodeling proportionally affects the airway wall and lumen dimensions such that their ratio is preserved. The objective of this study is to assess central airway wall area (WA), lumen area (Ai), and total bronchial area (Ao) from CT scans of 5,179 smokers and 92 never smoking normal subjects. In smokers, WA, Ai, and Ao were positively correlated with forced expiratory volume in 1 s (FEV1) expressed as a percent of predicted (FEV1%), and the WA% was negatively correlated with FEV1% (P < 0.0001 for all comparisons). Importantly, smokers with lower FEV1% tended to have airways of smaller cross-sectional area with lower WA. The increases in the WA% across GOLD stages of chronic obstructive pulmonary disease (COPD) can therefore not be due to increases in WA. The data suggest two possible origins for the WA% increases: 1) central airway remodeling resulting in overall reductions in airway caliber in excess of the decreased WA or 2) those with COPD had smaller native airways before they began smoking. In both cases, these observations provide an explanation for the limited range of values of WA% across stages of COPD.

The VANILLA sensor as a beam monitoring device for X-ray radiation therapy

Cancer treatments such as intensity-modulated radiotherapy (IMRT) require increasingly complex methods to verify the accuracy and precision of the treatment delivery. In vivo dosimetry based on measurements made in an electronic portal imaging device (EPID) has been demonstrated. The distorting effect of the patient anatomy on the beam intensity means it is difficult to separate changes in patient anatomy from changes in the beam intensity profile. Alternatively, upstream detectors scatter and attenuate the beam, changing the energy spectrum of the beam, and generate contaminant radiation such as electrons. We used the VANILLA device, a Monolithic Active Pixel Sensor (MAPS), to measure the 2D beam profile of a 6 MV X-ray beam at Bristol Hospital in real-time in an upstream position to the patient without clinically significant disturbance of the beam (0.1% attenuation). MAPSs can be made very thin (~20 μm) with still a very good signal-to-noise performance. The VANILLA can reconstruct the collimated beam edge with approximately 64 μm precision.

A standardized approach to the Fugl-Meyer assessment and its implications for clinical trials

BACKGROUND

Standardizing scoring reduces variability and increases accuracy. A detailed scoring and training method for the Fugl-Meyer motor assessment (FMA) is described and assessed, and implications for clinical trials considered.

METHODS

A standardized FMA scoring approach and training materials were assembled, including a manual, scoring sheets, and instructional video plus patient videos. Performance of this approach was evaluated for the upper extremity portion.

RESULTS

Inter- and intrarater reliability in 31 patients were excellent (intraclass correlation coefficient = 0.98-0.99), validity was excellent (r = 0.74-0.93, P < .0001), and minimal detectable change was low (3.2 points). Training required 1.5 hours and significantly reduced error and variance among 50 students, with arm FMA scores deviating from the answer key by 3.8 ± 6.2 points pretraining versus 0.9 ± 4.9 points posttraining. The current approach was implemented without incident into training for a phase II trial. Among 66 patients treated with robotic therapy, change in FMA was smaller (P ≤ .01) at the high and low ends of baseline FMA scores.

CONCLUSIONS

Training with the current method improved accuracy, and reduced variance, of FMA scoring; the 20% FMA variance reduction with training would decrease sample size requirements from 137 to 88 in a theoretical trial aiming to detect a 7-point FMA difference. Minimal detectable change was much smaller than FMA minimal clinically important difference. The variation in FMA gains in relation to baseline FMA suggests that future trials consider a sliding outcome approach when FMA is an outcome measure. The current training approach may be useful for assessing motor outcomes in restorative stroke trials.

Advanced rural skills training: are recently qualified GPs using their procedural skills?

INTRODUCTION

The number of GPs providing procedural services in rural areas is declining; however, few studies have investigated issues directly relevant to recently qualified doctors. Limited published data and anecdotal reports in Australia suggest that a large proportion of doctors leave rural procedural practice soon after training. This study aimed to: (1) describe where GPs practice in the 5 years after advanced rural skills training; (2) describe the proportion of doctors using their advanced skills; (3) measure doctors' ratings of the quality of support and how critical the year directly following training is in future career choices; and (4) measure the association between support and use of advanced skills.

METHODS

A cross-sectional, postal survey was undertaken of doctors who had completed advanced rural skills training in Queensland between 1995 and June 2009. Data were collected on a three-page, structured questionnaire. General practice colleges, the three Queensland regional training providers and one national training provider were approached in order to identify and mail questionnaires to eligible doctors. Descriptive statistics were prepared for practice history information, and attitudinal ratings. A χ(2) test was used to analyse the association between support and use of skills.

RESULTS

Sixty-one completed questionnaires were returned resulting in an unadjusted response rate of 51.7%. Respondents had completed a range of training posts: obstetrics and gynaecology (37.7%), anaesthetics (18%), anaesthetics and obstetrics and gynaecology (11.5%) and Aboriginal and Torres Strait Islander health (11.5%). Thirty-nine respondents (63.9%) were using skills related to their advanced training at the time of the study. In the first 5 years after training, the percentage of doctors using their advanced rural skills decreased from 75.4% to 61.1%. The year directly following advanced training was rated as 'critical' or 'very critical' in their future career choices by 68.9% of respondents. However, ratings of the quality of support received in that year were varied, with 21.4% reporting 'very poor' support. There was a statistically significant association between ratings of support in the year directly following training and the use of skills 3 years after training (χ(2) = 8.715, df = 2, p = 0.013).

CONCLUSIONS

This study has shown that while the majority of doctors are using skills related to their advanced rural skills training, there is room for improvement through training and career planning support, extending formal support mechanisms into the first year after training, improving opportunities to use advanced skills and improving systems to re-engage doctors into procedural practice.

Abstract 2889: Neural Systems Injury Provides Insight Into Individual Behaviors While Global Injury Is Useful For Global Outcome In Chronic Stroke

INTRODUCTION: A key challenge in the treatment of patients with chronic stroke is identifying which patients are most likely to benefit from therapy. An assessment of stroke-related injury can help, but it remains unclear which are the most useful measures. This issue was examined in the current study bearing in mind that restorative therapeutics in chronic stroke often target modality-specific behavioral measures such as arm motor function or aphasia. The hypothesis is that deficits in modality-specific behaviors are better understood by measuring injury to the neural system underlying the behavior, while deficits in global outcome assessments are better understood by measuring a global measure of injury such as infarct volume.

METHODS: Data were collected from pre-treatment assessments for patients enrolled in a study of robotic therapy for arm weakness after stroke (clinicaltrials.gov # NCT01244243 ). Entry criteria include age >18 yr, arm motor deficits, and stroke 3-6 months prior. Pre-therapy measures included assessment of global impairment (total NIHSS score) as well as arm motor deficits (Fugl-Meyer scale (FM); Action Research Arm Test (ARAT), and Box and Blocks (B&B)). Pre-treatment MRI (3T) included high resolution T1-weighted images, from which infarct volume was determined, and diffusion tensor imaging (DTI, 32 directions). DTI was used to determine corticospinal tract integrity by measuring fractional anisotropy (FA) within this tract. FA reflects the degree to which proton movements are directional, and so is higher in white matter tracts for which the axons are directional and intact, such as normal corticospinal tract.

RESULTS: Of the 28 enrollees, 25 were able to complete MRI scanning. These 25 had mild-moderate global impairment (NIHSS = 4.5 +− 2.3, mean +− SD) associated with arm motor deficits that were variable but overall moderate-severe (FM score = 34 +− 15, range 14-60). Arm motor deficits correlated more strongly with FA in the affected cerebral peduncle (r=0.70, p=0.0001 for FM score; similar for ARAT and B&B) than with infarct volume (r=-0.44; p=0.0546). Global impairment, however, correlated more strongly with infarct volume (r=0.66, p=0.002) than with FA in the affected cerebral peduncle (e.g, r=0-.57, p=.005 for FM). Note that in all cases, behavior/FA relationships were stronger with FA expressed as the ipsilesional/contralesional ratio, as compared to ipsilesional value alone.

CONCLUSIONS: In patients with chronic stroke, measuring injury to a specific neural system provides insight into the behavior arising from that system, and does so better than a global measure of injury. On the other hand, a global measure of neural injury correlates better with global outcome. These findings are useful for understanding injury underlying the deficits targeted by restorative therapies and might be useful for matching the right patients with the right therapies.

Abstract 2893: Robot-based Assessments Of Upper Extremity Function Are Valid And May Be Useful For Tele-outcomes After Stroke

INTRODUCTION: The increasing number of restorative stroke trials has generated increased discussion about optimal endpoints to detect changes in behavior over time. Robotic devices are under study as a therapeutic intervention, and in some cases the design of these devices might also make them useful for assessing behavioral status. If true, similar devices might be useful for remote assessment of behavioral status after stroke, i.e., tele-outcome. As an initial step, the current study examined the validity of 3 robot-based behavioral assessments.

METHODS: Data were collected at baseline for patients enrolled in a study of robotic therapy for arm weakness after stroke (clinicaltrials.gov # NCT01244243 ). Entry criteria include age >18 yr, arm motor deficits, and stroke 3-6 months prior. Pre-treatment assessments included the Fugl-Meyer Arm Motor Scale (FM-total), which has often been used as a behavioral endpoint in clinical trials, as well as 6 secondary, related tests: the Box/Blocks (B/B) Test, Action Research Arm Test, the hand/wrist subsection of the FM-total, hand motor subscale of Stroke Impact Scale-2, affected hand grasping force, and affected hand pinching force. These 7 tests were compared with score on robotic games that require targeting movements by wrist or by finger and that therefore emphasize movement speed and accuracy (using Bonferroni-adjusted p<0.007). In addition, score from the live version of the B/B test was compared with score from a robot-based version of the B/B test.

RESULTS: The 28 subjects were age 59 +/- 14 yr (mean +/- SD), stroke affecting R side in 14 and L in 14, and had moderate-severe impairment (FM-total scores = 34 +/- 15, range 14-60). Robot-based assessments were rapidly and successfully obtained in all subjects. Performance on the robot-based test of wrist targeting correlated significantly with baseline FM-total score (r = 0.73, p<0.0001) as well as all 6 secondary tests (r = 0.54 - 0.83, B/B score being highest). Performance on the robot-based test of finger targeting also correlated significantly with baseline FM-total score (r = 0.69, p<0.0001) as well as all 6 secondary tests (r = 0.52 - 0.70). Values of the live version (real blocks) and the robot-based version (virtual blocks) of the B/B test were correlated (r=0.48, p<.02). While 10 subjects demonstrated a floor effect on the live B/B test, only 2 subjects had a floor effect with the robot-based B/B test.

CONCLUSION: The current findings support the validity of robot-based methods for assessing upper extremity motor function in subjects with chronic stroke. Potential advantages of this approach as compared to traditional scales include simplicity, speed, and fewer subjects with a floor effect. In addition, the overall approach described here suggests the utility of tele-outcome assessments after stroke.

The effects of acute dynamic exercise on haemostasis in fi rst class Scottish football referees

PURPOSE

Physical fitness may confer protection from thrombosis; however, exercise-induced platelet activation may be involved in the triggering of acute vascular events. This study aimed to assess haemostatic responses to acute exercise in trained and sedentary middle-aged subjects.

METHODS

21 first class Scottish football referees and 15 sedentary controls performed a treadmill exercise test. Blood sampling was performed before, immediately after and 30 minutes post-exercise. Samples were analysed for platelet count, prothrombin time, activated partial thromboplastin time (APTT) and serum fibrinogen. Platelet activation was assessed using flow cytometry with CD62 (P-selectin) and antifibrinogen antibodies at rest and in response to ADP and epinephrine.

RESULTS

Mean maximal oxygen consumption (Vo2) (ml/kg per minute) achieved was 47.23 (5.02) in the referees and 30.1 (5.2) in sedentary controls. Total platelet count (x10(-9)/l) increased immediately post-exercise (228.2 (40.5), 278.6 (48.9) p=0.001) remaining elevated at 30 minutes in both groups. APTT (s) was reduced immediately post-exercise (32.15 (3.1), 29.7 (3.94) p=0.001) with a further reduction seen at 30 minutes (32.15 (3.1), 28.4 (3.31) p=0.001). In the referees, percentage CD62 expression increased immediately post-exercise (0.688 (0.52), 1.42 (1.3) p=0.008). Percentage antifibrinogen expression increased post-exercise (5.19 (4.31), 13.01 (14.24) p=0.017), with a further increase at 30 minutes (5.19 (4.31), 20.47 (26.8) p=0.02). Similar trends were seen in sedentary controls.

CONCLUSION

This study suggests that in an older athletic population, physical fitness does not protect against the prothrombotic effects of exercise. These data suggest that during a football match when referees achieve approximately 80% of peak VO2 (23) they may be at risk of significant platelet activation. Prophylactic platelet inhibition should be considered in this group after appropriate screening and risk stratification.

Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study

A safety-orientated system of delivering parenteral anaesthetic drugs was assessed in a prospective incident monitoring study at two hospitals. Anaesthetists completed an incident form for every anaesthetic, indicating if an incident occurred. Case mix data were collected and the number of drug administrations made during procedures estimated. From February 1998 at Hospital A and from June 1999 at Hospital B, until November 2003, 74,478 anaesthetics were included, for which 59,273 incident forms were returned (a 79.6% response rate). Fewer parenteral drug errors occurred with the new system than with conventional methods (58 errors in an estimated 183,852 drug administrations (0.032%, 95% CI 0.024-0.041%) vs 268 in 550,105 (0.049%, 95% CI 0.043-0.055%) respectively, p = 0.002), a relative reduction of 35% (difference 0.017%, 95% CI 0.006-0.028%). No major adverse outcomes from these errors were reported with the new system while 11 (0.002%) were reported with conventional methods (p = 0.055). We conclude that targeted system re-design can reduce medical error.

Use of within-group designs to test anti-tussive drugs in conscious guinea-pigs

INTRODUCTION

Cough is a common medical problem for which there are few effective drug treatments. A limited understanding of the mechanisms of induction and maintenance of cough and a paucity of suitable animal models frustrate drug discovery efforts to find novel anti-tussives. As in humans, guinea-pigs evoke a cough reflex upon exposure to tussive agents such as citric acid and capsaicin; both of which have been widely used to assess novel anti-tussive drugs. However, the potential for using within-group designs in drug development has received little attention and such designs may offer a way of assisting the drug discovery effort in the area of cough as well as other areas.

METHODS

Cough can be monitored in conscious guinea-pigs by placing animals in a Perspex chamber, in which air is continually exchanged by use of negative pressure and drug delivery of aerosols to the chamber can be accurately timed. Cough in response to a tussive agent (e.g. 0.2-0.4M citric acid; 10-30 microM capsaicin) is detected by the simultaneous microphonic recording of audible signals characteristic of the cough response as well as by positive pressure changes in the chamber generated by a cough dependent rapid expiration of air from the lungs. Both the sound and pressure signals are recorded using an online analyzer, whilst the number of coughs can be analyzed off-line. The number of coughs over a 15 min period is used to quantitate tussive events.

RESULTS

Reproducible cough can be detected in animals using cross-over designs that lend themselves to drug studies. Both the time and concentration dependence of anti-tussive drug action can be evaluated in the same animal. Furthermore, the effect of different anti-tussive drugs can be evaluated thereby reducing between group error and thereby improving the sensitivity of the test.

DISCUSSION

Repeated measures design improves the precision with which to evaluate anti-tussive drugs in preclinical models and could be used to make the drug discovery process more efficient.

Focal hand dystonia: effectiveness of a home program of fitness and learning-based sensorimotor and memory training

STUDY DESIGN

This was a pre post test design.

INTRODUCTION

Retraining the brain is one approach to remediate movement dysfunction resulting from task specific focal hand dystonia (FHD(TSP)).

PURPOSE

Document change in task specific performance (TSP) for patients with FHD(TSP) after 8 weeks of comprehensive home training (fitness activities, task practice, learning based memory and sensorimotor training).

METHODS

Thirteen subjects were admitted and evaluated at baseline, immediately and 6 months post treatment for task specific performance, functional independence, sensory discrimination, fine motor speed and strength. In Phase I, 10 subjects were randomly assigned to home training alone or supervised practice prior to initiating the home training. In phase II, 2 subjects crossed over and 3 new subjects were added (18 hands). The intent to treat model was followed. Outcomes were summarized by median, effect size, and proportion improving with nonparametric analysis for significance.

RESULTS

Immediately post-intervention, TSP, sensory discrimination, and fine motor speed improved 60-80% (p<0.00l respectively). Functional independence and strength improved by 50%. Eleven subjects (16 hands) were re-evaluated at 6 months; all but one subject reported a return to work. Task-specific performance was scored 84-90%. Supervised practice was associated with greater compliance and greater gains in performance.

CONCLUSIONS

Progressive task practice plus learning based memory and sensorimotor training can improve TSP in patients with FHD(TSP). Compliance with home training is enhanced when initiated with supervised practice.

Continuous spinal analgesia after extensive lumbar spine surgery

A 77-year-old male underwent L-1 to S-1 spine decompression and fusion from L-3 to S-1. A 25 G spinal catheter was placed intraoperatively and bupivacaine 1.25 mg/ml, fentanyl 2 microg/ml and morphine 3 microg/ml infused. The patient was pain-free for the duration of the infusion. Continuous spinal analgesia was effective after extensive spinal surgery. The risks of post-dural puncture headache, infection of wound and/or meninges and the optimum drug doses and combinations are yet to be quantified in this setting.